Key Info Form - Academy 4SC Learning Hub

Leaders 4SC Key Info Form

Student Name

Nickname/Preferred Name

Pronouns

Does your child have access to an electronic device (tablet/laptop) they can bring to the workshop?

Yes, a tablet.

Yes, a laptop.

No, they will not be able to bring an electronic device.

Adult T-Shirt Size

How will they be arriving/departing camp each day?

Parent/guardian will pick up and drop off

Another adult will pick up and drop off*

Self-dismiss (Public transit or walking)*

OtherOther

*If they will be dismissed to a person who is not a parent or guardian, please email [email protected] with the name of the person they are allowed to leave with. If they will be self-dismissing, please email [email protected] stating they have the permission to leave on their own and specify the mode of transportation they will be taking.

Primary Emergency Contact

First Name

Last Name

Primary Emergency Contact Phone number

Secondary Emergency Contact

First Name

Last Name

Secondary Emergency Contact Phone number

Any dietary restrictions or food allergies (Type “N/A” if none)

Any other allergies, medications, or medical conditions (Type “N/A” if none)

Any physical or learning accommodations required (Type “N/A” if none)

Additional Notes (Anything else we should be aware of)

If you are human, leave this field blank.